Sunday, July 31, 2011

NYT writer Dr. Pauline Chen correctly notes that this may drive medical students away from lower-paying primary care careers and into higher-paying specialties. One likely response from the government already hearing too many complaints from their constituents about a shortage of primary care doctors may be to step up programs such as the "Public Service Loan Forgiveness" for new medical graduates willing to work as primary care doctors in "underserved areas".

Now I have no problem with small rural communities making private deals with aspiring doctors to help pay for their education in exchange for a promise to work there for a certain number of years (i.e., a fully voluntary version of "Northern Exposure").

But if government policies artificially raise student indebtedness, then the government later lets them off the debt hook in exchange for the government telling them where to practice (according to the latest government guidelines of course), that's different.

Then it seems a little too much like a Mafia boss telling the storekeeper that his debt to the local loanshark will be forgiven if he'll let the Mafia decide what products he can (and cannot) sell in his neighborhood store and at what prices.

One woman waiting four months for a knee operation was told by a hospital that her name would drop off the list unless she replied to a letter, while a man had to pay £11,000 for a replacement hip after his doctors repeatedly refused to refer him for treatment. A multiple sclerosis sufferer claimed he had had to wait 18 months just to be added to a waiting list.

The examples emerged after The Daily Telegraph disclosed how health service funding bodies are artificially increasing waiting times as they wait for patients to die or go private.

Because of the problems of socialized medicine, the UK health providers are increasingly trying to "game" the system to make their statistics look better -- but at their patients' expense. Let's hope this doesn't start happening here in the US.

it is despicable for a government representative to contact a physician’s office to gather information under false pretenses. This is a sting operation designed to entrap decent, hard working medical office staff into saying things that could be recorded, taken out of context, refined into sound bites, and used to slander physicians. President Obama has already accused physicians of performing tonsillectomies just for the money. He has also stated that surgeons earn $50,000 for an amputation, which is grossly inaccurate. It is not far-fetched to suggest that the true purpose of this "study" was to gather doctor-bashing material to support Obamacare in the 2012 campaign. Their promise not to identify the responses of individual physician practices is of little comfort- in fact this would make it easier for them to "exaggerate" what was said to suit their purpose. It is incredible that Obama thinks nothing of spying on American citizens.

This "study" would have negative effects on health care. Office staff would no longer be able to trust the person on the other end of the phone. Doctors would have to pay an army of consultants to train office staff how to verify a caller’s identity before having any further conversation. Can you imagine the consequences to customer service and quality of care?

Just making the suggestion of this study serves the government’s true purpose- to intimidate physicians into behaving the way the government wants. This is not the first time. The WH has tried to intimidate us into reporting critics of Obamacare (remember "fishy" comments?). The government has bullied doctors for years with threatened pay cuts, an ever-increasing regulatory burden, and audits using outside contractors who are paid by the amount of fines they extract from their victims ("bounty hunters"), with no accountability regarding the accuracy of their audits.

Monday, July 25, 2011

President Obama has touted "comparative effectivness research" (CER) as a way to save money under his health care plan. In his words:

If there's broad agreement [that] the blue pill works better than the red pill, ...and it turns out the blue pills are half as expensive as the red pill, then we want to make sure that doctors and patients have that information available to them.

Although this sounds good at first glance, there are serious problems using this approach in a one-size-fits-all government health system.

In particular, they note that this approach can cause tremendous problems when policy-makers then treat patients as some sort of global "average" while neglecting their individual differences:

..[I]t is the drug or treatment with the larger average effect on an entire population that "wins." In the president's hypothetical, the blue pills are "just as effective" as the red ones because, on average, they do as much good for patients. But the average patient is not the same as any particular individual patient. Declaring a treatment most effective based on an average is a medical and an economic error, for two reasons.

First, individuals differ from one another and from population averages. Therefore, what may be on average a "winning" therapy may simply not work for a large number of patients. Conversely, a drug that is less effective on average may still be the best, or only, choice for a sizable proportion of patients.

The second reason is the variance in dependence in patient responses across therapies. Dependence, for any individual patient, is the degree to which response to one treatment predicts response to another. Dependence varies from illness to illness and from drug to drug but is often an important aspect of finding treatments that work. One cannot know in advance, as a general rule, that Drug A's failure guarantees the failure of Drug B. Yet a reimbursement policy based on CER could well make this error: by refusing to reimburse Drug B on the grounds that Drug A is "more effective," such a policy assumes that failure with Drug A will predict failure with Drug B.

The bulk of their paper discusses how this CER methodology would fail if applied to real-world antipsychotic drugs, where there are seeming equivalents of Obama's "red pill" and "blue pill".

Because of the factors mentioned above, a policy based on CER that restricted doctors' ability to prescribe (and patients' ability to receive) drugs deemed by the government as insufficiently "cost effective" would actually cost more money in the long run, as well as inflict tremendous and unnecessary hardship on patients.

Of course, CER data can be valuable to practicing physicians who treat patients as individuals. But it can be a dangerous tool when fallaciously misused by policy-makers who treat patients as a collective or an "average".

Saturday, July 23, 2011

Q: What's the difference between an ACO and a HMO?
A: An ACO is just like a HMO but with more government oversight. It will have the discipline of the Securities and Exchange Commission mixed with IRS-style responsiveness, all brought to you courtesy of CMS.

Q: What's the nicest thing a VP for Medical Affairs could spin about ACOs to a room full of skeptical doctors?
A: "It's not entirely without merit, but close."

Q: What is the difference between an ACO and quicksand?
A: People don't go into quicksand on purpose.

Q: Why is it called an "ACO?"
A: To honor the folks who thought of it: academics, consultants and Obama.

I'm still digesting Claeys' piece, but one of the many interesting points he makes pertains to the conventional wisdom that when the "individual mandate" is eventually decided by the US Supreme Court (SCOTUS), there will be 4 conservative votes against and 4 liberal votes for, with the "swing vote" being Justice Kennedy.

Claeys warns:

[T]his conventional wisdom is wrong -- and adhering to it could prove highly counterproductive for Obamacare's opponents. It is wrong largely because it assumes that the Roberts Court's 'judicial conservatives' are members of a monolithic bloc.

In the final section of the paper, he also discusses 4 principles that ObamaCare opponents should keep in mind as the SCOTUS decision draws here:

1. There should be no irrational exuberance about the Virginia and Florida decisions.

2. Obamacare opponents should not despair if the Supreme Court votes not to declare the individual mandate unconstitutional.

3. Opponents of Obamacare must anticipate what to say if the Supreme Court votes not to declare the individual mandate unconstitutional.

4. If legislators and candidates will need to argue against Obamacare's constitutionality later, they might as well start now. And they should consult the opinions of Justice Thomas.

In this study, researchers calculated the effect of health care reform on state and federal governments and the private health insurance markets, including employee contributions to their private insurance plans:

State health care expenditures have risen by $414 million over the period.
Private health insurance costs have risen by $4.311 billion over the period.
The federal government has spent an additional $2.418 billion on Medicaid for Massachusetts.
Over this period, Medicare expenditures increased by $1.426 billion.
This amounts to a total cumulative cost of $8.569 billion over the period.

The state has been able to shift the majority of the costs to the federal government.

This is clearly an unsustainable approach. The end-stage will have to be European-style rationing of health care. Let's hope the rest of America learns from the example of Massachusetts -- before it's too late...

Update:Investor's Business Daily also summarizes the BHI findings in their OpEd, "Massachusetts Mess".

"I will never forget watching my own mother... worrying about whether her insurer would claim her illness was a pre-existing condition," claimed Democratic presidential candidate Barack Obama, explaining the foundation of Obamacare. This too was a lie.

Recent revelations by author Janny Scott in "A Singular Woman: The Untold Story of Barack Obama's Mother" (Riverhead Hardcover, 2011), show that Stanley Ann Dunham, the president's mother, was in fact well-insured and, what's more, her health insurance company -- those evil corporatists -- never attempted to deny payment for her health care...

Dishonoring the dead with deception, as pathetic as that is, barely scratches the surface of the Obamacare falsehoods. You can keep your current doctor: Lie. You can keep your current insurance: Lie. Hearings will be made public: Lie. The deficit will be reduced: Lie. Four hundred thousand jobs will be created immediately: Lie. There are no death panels: Lie. Taxes won't be increased on families earning less than $250,000 a year: Lie. And all of this comes before the first Obamacare waivers exempted the White House's best friends from the rules that you must follow.

This degree of dishonesty is not merely taking a mulligan on the back nine or fudging a couple of pounds on your driver's license. There's something far more sinister at work here. America is being "fundamentally transformed" by deception...

He shows how candidate Obama (and later President Obama) twisted the truth of his mother's battle with cancer to create a politically useful -- but false -- narrative to justify his health care legislation.

Thursday, July 14, 2011

John Graham and the Pacific Research Institute have issued a report that "shows how ObamaCare threatens the solvency of private health plans, which will significantly reduce consumer choice and increase costs. The ultimate result will likely be either a massive taxpayer bailout of private health plans or continued momentum toward a single-payer government-monopoly system."

Graham's report studies Massachusetts and Colorado. He concludes that continued government controls of health insurance will create a "cascade of insolvency", eventually destroy the private insurance market, and leave consumers with little choice but a government insurance option.

He also notes that one tactic used by statists will be to blame the insolvencies on failures of the free market, whereas they will actually be the fault of the government controls.

Of course, his analysis extends to the other 48 states -- not just MA and CO.

The report Bust or Bailout? The Future of Private Health Plans Under Obamacare is available at the PRI website. It can be downloaded here.

Tuesday, July 12, 2011

Most doctors are very upfront about the fact that they cannot afford to accept unlimited numbers of government patients. As the article notes:

...71% of family physicians are accepting new Medicare patients, according to a September 2010 study. Physicians also were asked how Medicare payment cuts would impact their practices. Nearly 75% said they would limit Medicare appointments, and 62% said they would stop accepting new Medicare patients.

FIRM is honored to be one of the groups, projects, and organizations fighting for free-market health care reform listed in the new Black Ribbon Project poster! (Click on the image to see it full size.)

In the 1930s, the USSR forced independent farmers into large state-run collective farms. Despite possessing some of the richest farmland in the world, these collective farms could not feed the country. By the end of the Cold War, the USSR survived only by importing Western grain. Unfortunately, the United States is about to make the same mistake in health care by collectivizing doctors and hospitals into government-supervised accountable care organizations (ACOs)...

Note that this government-drive consolidation of doctors and hospitals into a few large provider groups is not some "bug", but rather a desired "feature", because it allows the government to more easily control what kind of medicine will (and will not) be practiced in the US.

Although this plan is ostensibly tabled for now, we must not simply let it slide by. This type of behavior is sinister and malevolent. What were HHS and the White House hoping to discover that they already didn't know? Physicians, of course, are limiting their practices to patients whose health insurance helps them meet their basic overhead of running a practice. If they don't stay in business, patients can't be treated.

For an Administration that has recognized that there is already a doctor shortage and that patients today have to wait longer to see a doctor, it certainly is disingenuous to make a "phony" appointment for a patient and takes a slot from someone who might desperately need it.

The greater problem is not with doctors, but with a government-run healthcare system (Medicaid, Medicare, state children's health plans) that has set reimbursements so arbitrarily low, that doctors cannot rely on it to pay the bills. The solution is not to conduct survey to gather information we already know. It is to allow patients to have financial control of their healthcare. In short, the government needs to get out of the healthcare business.

The information garnered from any potential survey would have undoubtedly been used by President Obama to blame doctors for the healthcare access problem. We could then expect a heavy handed response from the government to get doctors to behave, perhaps telling them that in order to practice medicine they must accept Medicaid patients or others on government programs. This is a formula that Massachusetts has been trying to enact since Gov. Mitt Romney implemented his health reform plan. After that, government could instruct doctors on just about anything including edicts on how many patients they see daily.

Some may think this is farfetched or paranoid. But then again, who expected Obamacare to get this far?

Doctors are right to be mistrustful, given the Administration's lack of transparency through the health care process, including how the legislation was passed with back-room deals and how ObamaCare waivers were mysteriously granted to those with political connections.

Prediction: Look for a revival of this "secret shopper" idea after the 2012 elections are over...

Friday, July 8, 2011

In the 7/5/2011 Health Reform Report, Dr. Richard Amerling discusses the latest attempted "reform" and what's wrong with it. Here's an excerpt from, "The End of Fee-for-Service Medicine":

The payment transition from the current fee for service to salaried status also also creates a loss of autonomy for physicians. Doctors will have no choice but to follow hospital dictates regarding length of stay, choice of medicine, and adherence to clinical practice guidelines, many of which are either obsolete or inappropriate. The practice of medicine will become textbook instead of individualized to the patient...

The payment transition from the current fee for service to salaried status also also creates a loss of autonomy for physicians. Doctors will have no choice but to follow hospital dictates regarding length of stay, choice of medicine, and adherence to clinical practice guidelines, many of which are either obsolete or inappropriate. The practice of medicine will become textbook instead of individualized to the patient...

FFS has been wrongly blamed for runaway health spending, when the real culprit is the third party system, unrestrained by meaningful co-pays or deductibles...

Dr. Amerling has it absolutely right. Eliminating fee-for-service will create perverse incentives for doctors and will ultimately harm patients.

Medical organizations should be left free to work out the best incentive structures that suit their particular needs and circumstances. It may include straight salary, salary-plus-productivity-bonus, or pure fee-for-service. For government to declare any one model as wrong and compelling doctors to work under its preferred system violates the rights of doctors and patients to contract to their mutual interest according to their best judgment.

Dr. Milton Wolf has a new piece in the 7/7/2011 Washington Times on signs of panic in the Obama administration over their failing policies, including the multiple ObamaCare "waivers". Read more at: "'No Drama' Obama Losing His Cool".

Wednesday, July 6, 2011

The folks at personal genetic testing company 23andme.com recruited Parkinson's Disease (PD) patients from mailing lists and other means and compared their genetic variants with a group of 23andMe customers who also got their genetic variants tested by 23andMe.

We conducted a large genome-wide association study (GWAS) of Parkinson's disease (PD) with over 3,400 cases and 29,000 controls (the largest single PD GWAS cohort to date). We report two novel genetic associations and replicate a total of twenty previously described associations, showing that there are now many solid genetic factors underlying PD. We also estimate that genetic factors explain at least one-fourth of the variation in PD liability, of which currently discovered factors only explain a small fraction (6%–7%). Together, these results expand the set of genetic factors discovered to date and imply that many more associations remain to be found.

Unlike traditional studies, participation in this study took place completely online, using a collection of cases recruited primarily via PD mailing lists and controls derived from the customer base of the personal genetics company 23andMe.

Our study thus illustrates the ability of web-based methods for enrollment and data collection to yield new scientific insights into the etiology of disease, and it demonstrates the power and reliability of self-reported data for studying the genetics of Parkinson's disease.

You can read the whole open access Plos Genetics research report at that link.

What's cool about this: Using a web site and cheap genetic testing services people can volunteer themselves as research subjects on a scale that historically has taken far more effort to organize. This approach can scale into the hundreds of thousands, and even hundreds of millions of people. There's a big network effect where the more people who get tested the more useful genetic testing becomes.

Direct-To-Consumer (DTC) genetic testing is what made the study above possible. Whether we will be able to continue to get our DNA tested without paying for a doctor's visit and additional testing mark-ups remains to be seen. In the United States the Food and Drug Administration (FDA) is taking a dim view of DTC genetic testing.

I completely agree with Parker. Proposed FDA controls over the growing consumer genetic testing market not only deprive individuals of the right to learn the content of their DNA, but could also stifle the growth of new discoveries (and downstream therapies) made possible only by this sort of innovative free-market "crowdsourcing".

The FDA has no business stopping people from voluntarily sharing their genetic information with others in hopes that they might reap life-saving benefits.

At the American Thinker blog ("ObamaCare: The Antithesis of the Founders' Vision"), Joshua Lipana posts about a recent article in The Objective Standard covering the lawsuit filed by Iraq war veteran Matt Sissel challenging the individual insurance mandate.

The TOS article, "ObamaCare v. the Constitution", was written by attorney Paul Beard of the Pacific Legal Foundation, representing Sissel. Beard covers the basic legal arguments in a fashion accessible to the layman.

Beard's piece does a nice job of covering the essential legal issues -- as well as putting a human face on what an individual mandate would mean.

In an age of family physicians literally not being able to give away their practices, Brian Forrest has built a successful model that is similar to the age of Marcus Welby where there was a direct relationship between a patient and their doctor. Practices such as Forrest's Access Healthcare in North Carolina run unencumbered by insurance hassles.

As word of Dr. Forrest's direct pay practice has spread, he has had a constant stream of physicians visiting his practice so others could learn how he has a successful financial model, happy patients and a sane lifestyle -- something increasingly less common in the hamster-wheel model of primary care that is prevalent in current fee-for-service based primary care practices. Dr. Forrest runs a cash-only practice sees 16 patients a day at a maximum, works a 40 hour week and takes home more than the average family physician a year with a highly satisfied patient base that pays less than those in fee-for-service, insurance models.

Dr. Forrest embodies a rapidly expanding cohort of what could be called Do-it-Yourself Health Reformers. That is, they aren't waiting around for politicians to fix what is widely understood to be the broken facets of healthcare. Rather, through their own trial and error, they are refining care and payment models that are demonstrating impressive results...

Saturday, July 2, 2011

For years, Canadians have crossed our northern border to access procedures not available in their government-only system, where the average wait in 2010 from seeing a primary care doctor to getting treatment by a specialist was 18.2 weeks. I don't imagine it will take long for those same patients and Americans to find their way to Istanbul or Bangkok.

While medical tourism is not appropriate for every situation or procedure, it is the wave of the future as patients look for affordable and timely care. Self-insured employers will surely look for better ways to cover their employees that don't jeopardize their businesses. It happened with the car industry back in the 1970s and is going to happen to U.S. health care.

Americans will find their way to the "best value" in health care. Sadly for American doctors and hospitals, that may soon be overseas.

In fact, Credit Suisse has told clients that forcing employers to drop coverage is "exactly what was intended" by the law. This was the main goal of many advocates of ObamaCare --to completely replace private insurance with a single-payer government healthcare system.

In particular, he cites the case of the FDA using unrealistically strict criteria to reject a melanoma (skin cancer) detection device. In particular, he notes:

But even if MelaFind is not perfect today nor appropriate in all circumstances it’s exactly the type of innovation that we should encourage. Devices such as MelaFind could not only improve medical care they can reduce costs and make good quality medical care more widely available in developing countries, for example, where experienced dermatologists are in short supply.

Most importantly, innovations get better over time. But if you impede the first generation the second generation may never come into existence and, as Mandel notes, no first-generation device could satisfy the FDA's conditions. It's like refusing to give the Wright Brothers a license to fly because their first airplane only flew for 59 seconds...

By stifling promising fledgling technologies in their infancy, the FDA thus deprives us of countless future improved versions as well. But because we don't know what will never be invented, we don't know what life-sustaining benefits we're missing out on.

The FDA's policies thus represent just another (deadlier) version of Bastiat's principle of "the seen vs. the unseen".

About FIRM

America was founded on the principles of freedom and individual rights. Applied to medicine, the law must respect the individual rights of doctors and other providers, allowing them the freedom to practice medicine. This includes the right to choose their patients, to determine the best treatment for their patients, and to bill their patients accordingly. In the same manner, the law must respect the individual rights of patients, allowing them the freedom to seek out the best doctors and treatment they can afford.

Freedom and Individual Rights in Medicine (FIRM) promotes the philosophy of individual rights, personal responsibility, and free market economics in health care. FIRM holds that the only moral and practical way to obtain medical care is that of individuals choosing and paying for their own medical care in a capitalist free market. Federal and state regulations and entitlements, we maintain, are the two most important factors in driving up medical costs. They have created the crisis we face today.

Freedom and Individual Rights in Medicine was founded by Lin Zinser and Paul Hsieh, MD in 2007. It is now managed by Paul Hsieh, MD.